The document discusses the anatomy and classification of acetabular fractures. It notes that Judet and Letournel analyzed the anatomy of the innominate bone and established planes and angles. Acetabular fractures are classified using the Judet and Letournel or Orthopaedic Trauma Association systems. Treatment may involve non-operative management with traction or surgery depending on the fracture pattern and stability. Surgical approaches are dependent on the specific fracture location and goal is anatomic reduction to restore a congruent joint. Complications can include arthritis, heterotopic ossification, nerve injuries and infection.

2. Acetabular supports:
2 Columns (Inverted “Y”) &
Sciatic buttress
Judet & Letournel

3. Judet & Letournel
Analysed inominate bone anatomy.
Plane of Ilium & Obturator foramen ~ 90o
450
to frontal plane
X rays at 45 oblique views.

4. Anatomy of acetabulum:
Incomplete
hemispherical socket
Horse shoe shaped
articular facet
Non articular condyloid
fossa

5. Anatomy:
Anterior Column -
longer
Posterior Column -
shorter
Sciatic notch

6. Dome or roof –
weight bearing portion
Goal of treatment
Anatomic restoration of
dome
Concentric reduction of
femoral head within
dome

8. Neurovascular structures
External iliac A.

9. Sciatic N.
Superir gluteal
A. & N.
Greater sciatic
notch

10. Mechanism of Injury:
Transmitted Force
Femur
Femoral head
Pelvis and acetabulum

11. Fracture pattern
Dependent upon:
Position of hip
Direction & magnitude of Impact
Osteoporotic bones
Other injury patterns.
DIAGS

12. Hip flexed –Posterior wall # Dislocation
Internal rotation & adduction – Dislocate without
fracture.
Neutral hip - # posterior wall
Abducted position – Transverse # with posterior wall

13. Magnitude of force / displacement –
degree of comminution
Degree of articular impaction
Strength of the bone.

14. Clinical Evaluation:ABCD
Life threatening injuries
HEMODYNAMIC STABILITY
Superior gluteal A. or V.
Selective angeography
Head, chest, abdomen
57% have other associated injuries.
Secondary survey – knee, patella, ligaments.

15. Morel Lavalle lesion
Skin
Subcutaneous degloving, hematoma.
Fluid wave, fluctuent
Circumscribed area of anaesthesia / Echymosis
Culture
Significance in surgical treatment.

16. Neurological injuries
30% partial injuries to sciatic N.
More commonly peroneal division.
Superior gluteal N.
Impossible to assess abductor strength in acute
fractures.

17. Dislocation may be missed on examination
X rays needed
Dislocation – Urgently reduced
Osteonecrosis femoral head.
Wearing of head against intra articular fragments
Urgent skeletal traction.

18. Associated injuries:
Posterior pelvic ring disruption –
reduction and fixation prior to acetabular # treatment.
Recreate a stable posterior pelvis to reduce the
acetabulum to.
Contralateral rami #s
Intraop traction not used
Concurrent symphysis dislocations.

19. Radiographic evaluation:
Pelvis AP view
Judet views – 45 degree oblique
Aid in classification
Identify # displacements.
OUT OF TRACTION
Painful – premedication.
Pelvic inlet / Outlet views – useful but not
mandatory

20. Pelvis AP viewX ray
view
Information
regarding
1Iliopectin
eal line
Anterior
column
2 Ilioischial
line
Posterior
column
3 Tear
drop
Relationship of
columns
4 Roof
(Sourcil)
Superior
articular
surface
5 Anterior
Lip
Anterior
column or wall
6 Posterior
lip
Posterior
column or wall

21. Iliac ObliqueX ray view Information
regarding
1 Greater &
Lesser sciatic
notch
Posterior column
(Posterior border
of innominate
bone)
Quadrilateral
surface of
ischium
Posterior column
(Posterior border
of innominate
bone)
2 Anterior lip Anterior column
or wall.
Iliac wing Anterior column
Roof Superior articular
surface

22. Obturator oblique
X ray view Information
regarding
1Iliopectinea
l line / Pelvic
brim
Anterior column
2Posterior
rim or lip
Posterior
column or wall
Obturator
ring
Column
involvement
Roof Superior
articular surface

23. C. T. ScanRotational displacements
Intra articular fragments
Marginal articular
impaction
Associated femoral head
injuries
Size of posterior wall
fragment.
3-D RECON
Relationship of multiple sites
of injury

24. Dry bone model or Line drawing:
Fracture pattern
Drawing the fracture lines from X ray landmarks
Should be drawn always before surgery.
Fracture pattern truly appreciated.

25. Fracture Classification:
Judet and Letournel Classification
Orthopaedic Trauma Association Classification

26. Fracture Classification
of Letournel and Judet
A ELIMENTARY FRACTURES
1 Posterior wall 30%
2 Posterior column 3-5%
3 Anterior wall 1-2%
4 Anterior column 3-5%
5 Transverse 5-19%
B ASSOCIATED FRACTURES
1 Posterior column + wall 3-4%
2 Anterior + posterior Hemitransverse
7%
3 Transverse + posterior wall 20%
4 T – shaped 7%
5 Associated both column ABC 23%

27. Treatment options:
Non surgical treatment
Operative treatment

28. Non-operative treatment
Unlike most articular #s having specific operative
indications acetabular #s are
generally considered requiring operative treatment
Unless certain non-operative criteria are met.
Other factors – fracture displacement and location,
stability of hip & patient related factors.

29. Criteria for Non-operative
Management (Four)
Roof arcs >45 degrees.
No fracture involvement in cranial 10 mm of joint on
CT (CT subchondral arc).
No femoral head subluxation on three x-rays, taken
out of traction.
For posterior wall fractures: less than 40% of width of
wall on CT .
Criteria by Olson & Matta

30. Roof arch measurements:
Way to quantify the intact weight bearing articular
surface (WBD).
In AP, Obturator and Iliac views.
Correlates with 10mm of acetabular WBD on CT
Not applicable in
ABC
Posterior wall

31. Other factors
ABC
No intact acetabulum left to measure
Perfect secondary congruence
Posterior wall
>50% width all unstable hips
<25% width all stable

32. Displacement <2mm – non-operative treatment
regardless of location.
In WBD – careful X ray follow up.
Stress views may be needed (Tornetta modified
criteria of Olson & Matta).

33. Patient related factors
Age
Preinjury activity level
Functional demands
Medical comorbidities
Old patients
Planned arthroplasty once arthritis develops.

34. Operative Treatment:
Earlier the better once decided to operate.
After 3 wks – results not good.
Not an emergency except
Irreducible hip dislocation
Progressing neurological deficits
Open #s
Vascular injuries

35. Surgery
ORIF - treatment of choice
GOAL
Anatomic reduction of articular surface
Avoiding complications
Restoring congruent joint
Stable hip
Maximize the potential for long term survival of hip.

36. Accuracy of reduction
Correlates with clinical outcome.
<1mm Excellent results
1-3mm good/fair.
>3mm poor results.

37. Closed reduction and percutaneous fixation –
proposed for
elderly patients &
Simple fractures with minimal displacements.
No long term results available yet.

38. Methods of Non Operative care:
Skeletal traction
Mainly historical importance in displaced, unstable #s.
Acute situation.
Polytraumatized sick patient
Supracondylar femur traction (Never trochanteric –
infection).
Early ambulation, Limited and progressive weight
bearing

39. Early ambulation, Limited and progressive
weight bearing
Mobilization with protected wt bearing – 10-30Lb
TDWB
If bilateral – transferred in bed to chair manner.
Early CPM
Weight bearing at min 8 weeks
Certain of stability if any doubt – Dynamic stress
views.
Serial X-rays – late subluxation or loss of position
of articular fragments.

40. Surgical indications:
Loss of congruence (Subluxation) of hip on any
view (AP or Judet x-rays)
Displacement of >2 mm within the superior
articular surface (weightbearing dome)
Retained intraarticular fragments,
Greater than 25% of the width of the posterior wall
on CT or demonstrable instability.
Lack of secondary congruence for an associated
both column fracture.

41. Other factors favoring operative
intervention:
Sciatic N lesion developing
following closed reduction or
while in traction.
Associated fracture of femur
Traction not possible
Ipsilateral knee disruption
Patellar fracture or posterior ligamentous injuries.

42. Indications for Emergency ORIF
Irreducible dislocation, usually by
Large fragments of bone within the joint
Soft tissue interposition.
Head buttonholed through capsule.
Unstable hip following reduction
Increasing neurologic deficit
Before reduction–Urgent closed reduction
After reduction-Urgent Open reduction.
Associated Vascular injury – mc anterior column
fractures.
Open fractures.

43. Contraindications
In Patient
Very osteoporotic
Severe associated injuries
In Fracture
Very comminuted inoperable fracture
In Surgical team
Not experienced in such surgeries
No expert help available.

44. Role of THR
Should not be used for fractures best treated by ORIF
Older pateints, with poor bone or extensive
comminution with probable poor results.

45. Surgical approaches:
FRACTURE TYPE APPROACH
ELIMENTARY FRACTURES
1 Posterior wall Kocher-Langenbeck
2 Posterior column Kocher-Langenbeck
3 Anterior wall Ilioinguinal
4 Anterior column Ilioinguinal
5 Transverse
Infratectal/Juxtatectal
Transtectal
Kocher-Langenbeck
Extended iliofemoral
or Kocher-Langenbeck

46. Surgical Approaches:
ASSOCIATED FRACTURES
1 Posterior column + wall Kocher-Langenbeck
2 Anterior + posterior
Hemitransverse
Ilioinguinal
3 Transverse + posterior wall
Infratectal/Juxtatectal
Transtectal
Kocher-Langenbeck
Extended iliofemoral
or Kocher-Langenbeck
4 T – shaped
Infratectal/Juxtatectal
Transtectal
Kocher-Langenbeck or
combined
Extended iliofemoral
or combined
5 Associated both column ABC Ilioinguinal.

47. Complications:Post traumatic arthrosis
Heterotrophic Ossification
Venous thromboembolism - 61%
Neurologic injury
Sciatic –
 30% of acetabular #s
 2 -3% iatrogenic after surgery.
LFCN (m.c. N. injury after surgery)
Infection 1-10% after surgery.